Subcutaneous lispro and intravenous regular insulin treatments are equally effective and safe for the treatment of mild and moderate diabetic ketoacidosis in adult patients

Ersöz, Halil Önder; Ükinç, Kubilay; Köse, Mustafa; Erem, Cihangir; Gunduz, Abdülkadir; Hacıhasanoğlu, Arif; Karti, S.

doi:10.1111/j.1368-5031.2006.00786.x

Cited by 76 publications

(51 citation statements)

References 16 publications

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“…Studies comparing treatment of DKA using subcutaneous or intramuscular insulin against conventional IV insulin infusions found slower plasma glucose reductions at 1 h (failure to reduce by 10%) (55) and at 3 h (56) and slower ketone clearance (56). …”

Section: Resultsmentioning

confidence: 99%

Review of Evidence for Adult Diabetic Ketoacidosis Management Protocols

et al. 2017

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BackgroundDiabetic ketoacidosis (DKA) is an endocrine emergency with associated risk of morbidity and mortality. Despite this, DKA management lacks strong evidence due to the absence of large randomised controlled trials (RCTs).ObjectiveTo review existing studies investigating inpatient DKA management in adults, focusing on intravenous (IV) fluids; insulin administration; potassium, bicarbonate, and phosphate replacement; and DKA management protocols and impact of DKA resolution rates on outcomes.MethodsOvid Medline searches were conducted with limits “all adult” and published between “1973 to current” applied. National consensus statements were also reviewed. Eligibility was determined by two reviewers’ assessment of title, abstract, and availability.ResultsA total of 85 eligible articles published between 1973 and 2016 were reviewed. The salient findings were (i) Crystalloids are favoured over colloids though evidence is lacking. The preferred crystalloid and hydration rates remain contentious. (ii) IV infusion of regular human insulin is preferred over the subcutaneous route or rapid acting insulin analogues. Administering an initial IV insulin bolus before low-dose insulin infusions obviates the need for supplemental insulin. Consensus-statements recommend fixed weight-based over “sliding scale” insulin infusions although evidence is weak. (iii) Potassium replacement is imperative although no trials compare replacement rates. (iv) Bicarbonate replacement offers no benefit in DKA with pH > 6.9. In severe metabolic acidosis with pH < 6.9, there is lack of both data and consensus regarding bicarbonate administration. (v) There is no evidence that phosphate replacement offers outcome benefits. Guidelines consider replacement appropriate in patients with cardiac dysfunction, anaemia, respiratory depression, or phosphate levels <0.32 mmol/L. (vi) Upon resolution of DKA, subcutaneous insulin is recommended with IV insulin infusions ceased with an overlap of 1–2 h. (vii) DKA resolution rates are often used as end points in studies, despite a lack of evidence that rapid resolution improves outcome. (viii) Implementation of DKA protocols lacks strong evidence for adherence but may lead to improved clinical outcomes.ConclusionThere are major deficiencies in evidence for optimal management of DKA. Current practice is guided by weak evidence and consensus opinion. All aspects of DKA management require RCTs to affirm or redirect management and formulate consensus evidence-based practice to improve patient outcomes.

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Section: Resultsmentioning

confidence: 99%

Review of Evidence for Adult Diabetic Ketoacidosis Management Protocols

et al. 2017

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“…The study found no statistically significant difference in the length of hospital stay, duration of treatment, or amount of insulin received among the study groups. These findings were supported by another article with a smaller sample size 3 , and a 2016 Cochrane Review 4 of this topic concluded that, on the basis of low quality evidence, treatment of DKA with subcutaneous insulin was neither superior nor inferior to IV insulin.…”

Section: Marlene Aziza Azar Is a Fourth Year Medical Student Atsupporting

confidence: 65%

Treating diabetic ketoacidosis with subcutaneous insulin?

Azar¹

2017

Clin. Res. Prac.

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“…76 Potential candidate patients include those who are alert and do not otherwise need admission to a critical care area, have a pH above 7.0, and bicarbonate of at least 10 mmol/L (≥10 mEq/L) 77. Four prospective randomized studies in adult patients with diabetic ketoacidosis compared subcutaneous rapid acting insulin (initial bolus of 0.3 units/kg followed by 0.1-0.2 units/kg every 1-2 hours) with conventional diabetic ketoacidosis treatment and found no difference in patient outcomes 77787980. With subcutaneous insulin regimens, administration of intravenous fluids and electrolytes, as well as monitoring, is identical to what is recommended with intravenous insulin therapy.…”

Section: Acute Managementmentioning

confidence: 99%

Diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome: review of acute decompensated diabetes in adult patients

French

Donihi

Korytkowski

2019

BMJ

135

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Diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome (HHS) are life threatening complications that occur in patients with diabetes. In addition to timely identification of the precipitating cause, the first step in acute management of these disorders includes aggressive administration of intravenous fluids with appropriate replacement of electrolytes (primarily potassium). In patients with diabetic ketoacidosis, this is always followed by administration of insulin, usually via an intravenous insulin infusion that is continued until resolution of ketonemia, but potentially via the subcutaneous route in mild cases. Careful monitoring by experienced physicians is needed during treatment for diabetic ketoacidosis and HHS. Common pitfalls in management include premature termination of intravenous insulin therapy and insufficient timing or dosing of subcutaneous insulin before discontinuation of intravenous insulin. This review covers recommendations for acute management of diabetic ketoacidosis and HHS, the complications associated with these disorders, and methods for preventing recurrence. It also discusses why many patients who present with these disorders are at high risk for hospital readmissions, early morbidity, and mortality well beyond the acute presentation.

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Subcutaneous lispro and intravenous regular insulin treatments are equally effective and safe for the treatment of mild and moderate diabetic ketoacidosis in adult patients

Cited by 76 publications

References 16 publications

Review of Evidence for Adult Diabetic Ketoacidosis Management Protocols

Review of Evidence for Adult Diabetic Ketoacidosis Management Protocols

Treating diabetic ketoacidosis with subcutaneous insulin?

Diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome: review of acute decompensated diabetes in adult patients

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